Monday, May 26, 2014

Recently I wrote about indemnity insurance: who benefits?
The insurance company is a business that can only exist if it protects the interests of its shareholders and employees. In that article I wrote:

It
does seem to me that privately practising/independent midwives will 'die out'
as soon as the laws mandating indemnity insurance are applied. Because
the stakes are so high in childbirth, insurance becomes too expensive
except through large
corporations (hospitals) or medical defense schemes which cost more
than some midwives earn.

Today I would like to focus on a case study, published recently by an
insurer of midwives, guiding midwives in the potentially difficult
scenario of the client who refuses to follow a midwife's advice.

The case study, titled Terminating the midwife/client relationship(April 2014) suggests that midwives can be insured only if there is zero tolerance for departure, by the midwife or the client, from a very narrow compliance pathway. That in a situation where the client declines advice from the midwife, the midwife will jump ship - terminate the relationship she has with that client.

I think the advice in this case study is wrong, and MIGA needs to withdraw it.

Many readers will know MIGA is the insurance company that
provides professional indemnity insurance (PII) for independent midwives, underwritten by Treasury. It's
the only option for midwives who have hospital visiting access. That's a monopoly.
The big issue of concern in this case study is: "The client signed a service agreement with the midwife agreeing to
comply with the requests and recommendations of the midwife."

???

agreeing [UP FRONT] to
comply ... !

Is that reasonable?

What's the point of rhetoric like 'informed decision making' in that sort of relationship?

There is no legal obligation that I know of (outside of this sort of
service agreement that has been made by the risk management/legal team
of the insurer) to ask a woman to sign over her rights, particularly the
right of refusal, which is a human right.

Midwives practising privately, who are planning to
attend homebirth, are required by NMBA to have a statement signed by the client
that she understands there is no PII for homebirth with a midwife.

The
relevant provisions of the National Law and the Board’s requirements are:

Section
284(1)(b) informed consent has been given by the woman in relation to whom the
midwife is practising private midwifery

Informed
consent must be given by the woman who is the client of the midwife who is in
private practice.Informed consent
is defined specifically as written consent given by a woman after she has been
given a written statement by a midwife that includes:

·a statement that appropriate PII arrangements
will notbe in force in relation to the midwife’s practice of private
midwifery in attending a homebirth, and

The case study is based on a scenario in which the midwife believes her ability to care safely for the woman and her baby has been irretrievably compromised, because the woman, now ten days past her 'due date', declines consultation with and review by a doctor/ hospital antenatal clinic.

I want to express surprise at this scenario, and I realise that the MIGA team who prepared this case study probably sent it to one of the midwives insured with them for checking and review. That thought only adds to my sense of concern! The scenario presented is hardly a decision
point that could be the cause of irretrievable compromise to the
relationship. Most privately practising midwives would have experienced this scenario many times. The clinical scenario described in the case study is certainly a point for discussion and accurate documentation, but in my mind it would be unthinkable to abandon the woman at that point, on such flimsy grounds.

The case study mentions the ACM guidelines
which list post-term pregnancy (7.1.22) as >42 weeks (not 41+3), category B
- 'consult' - which may be with another midwife. The guidelines have a guiding principle of informed choice
(3.2.2), stating that "The woman is free to accept of reject any
procedure or advice".

Notions of a woman's right to decline, and to make informed decisions in any professional care situations are well established. The midwifery profession cannot provide safe professional services for women if such blatant and uninformed control is delegated to the insurer, whose primary interest may not be the safety and wellbeing of mother and child. The scenario described in this particular case study could very easily leave a woman feeling that she has no option than to 'free birth', without any professional attendance.

Tuesday, May 20, 2014

[I have posted these comments on a social media site that might not be
accessed by many of my readers, so have copied and expanded it here.]

A blog post by UK midwife-author-teacher Sarah Wickham, questioning the Australian regulation of midwives, provides comment on the UK model of supervision of midwives.

I
share Sarah Wickham's concern, when midwives are subjected to
"vexatious reporting and persecution in a number of ways, simply for
supporting women’s choices."Without
pointing the finger at any person, and I wasn't at the recent homebirth
conference in Brisbane, I think it's likely that Sarah has heard only a fraction of
the story. In my opinion there have been too many cases recently, some on public record, in
which midwives have hidden behind a notion of the woman's choice, when
in fact there was no discussion of escalation of care and appropriate
intervention. Midwifery partnership can only be achieved when the
conversation between the midwife and the woman is ongoing, and informed
*decisions* are made rather than choices.

An effective program of
professional supervision of midwives could, theoretically at least, support the
midwife in real time whose client is making an informed decision that
does not follow usual professional advice. This would apply whether the midwife was in private practice or employed in a hospital or other birthing facility. The UK model of supervision of midwives is for all midwives.A midwife can't afford to be a true believer, or to 'trust birth' in any
idealistic way, even though we act to promote, protect and support
normal birth and the physiological adaptation of the newborn to life out
of the womb. The
setting/place of birth (home/hospital) has become an obstacle in this country to good
midwifery practice, because privately practising midwives are restricted
to homebirth. The exclusion of PP midwives from mainstream hospital is
not in the interests of wellbeing and safety of mother and baby, and
probably contributes in complex (and unaccountable) ways to some adverse
outcomes. The midwife's duty of care includes what we do in
emergencies, and accessing medical (ie hospital) help in a timely
manner. The
introduction of the wonderful www, and social media, and digital communication ... has had a profound
impact on some women's access to information about birth, and their
choices. Anyone who remembers 20 years ago, when homes didn't have
internet access, and mobile phones were great big clunky devices, will know what I mean. Now women tell me they have
'researched' their choices, as though it's done and dusted. The rise
and rise of freebirthing is very much an internet phenomenon.Please keep the conversation happening.

Monday, May 19, 2014

This is an amazing old piece of stitching.
But, I don't think it is meant to represent a ruptured uterus!

Recently, the Nurses and Midwives Board of Australia (NMBA, or Board) has invited midwives to participate in a series of focus groups and consultations that will lead to a process of supervision for privately practising midwives. I and a number of other midwives and stakeholders have been invited to participate in three expert consultations with the law firm, Pricewaterhouse Coopers (PwC) that has been engaged to oversee the project, and advise on potential models.

This midwife supervision project
is all about the statutory duty (of the NMBA) to provide a level of protection
for the public through regulation and support of the midwifery profession. Whether
or not they introduce supervision for PPMs, or for all midwives, and what it
will look like (how supervision will work) is unknown. Note that
the Board has recently replaced its ‘Safety and quality framework for midwives
attending homebirths’ with a SQF for all midwives http://www.nursingmidwiferyboard.gov.au/News/2014-04-30-safety-and-quality-framework.aspx

If you are a midwife who has worked in the United Kingdom, you will know that all midwives there have a supervisor, who answers to the local regulatory authorities, who in turn answer to the national regulator. The process is at present being reviewed. [See Parliamentary and Health Services Ombudsman's Conclusions and Recommendations -added to this post 19/6/14]

The current model of supervision, in the UK context, is a "means of promoting excellence in midwifery care, by supporting midwives to practise with confidence ...", and a means of protection of "women and babies by actively promoting a safe standard of practice." (NMC 2009. Modern Supervision in Action: a practical guide for Midwives, p3)

That two-sided goal, to protect mothers and babies, at the same time as supporting midwives, is what statutory regulation seeks to provide. A process that is focused solely on weeding out those midwives who may have performed poorly in a particular situation is unbalanced and probably unnecessarily punitive. A process that is focused solely on supporting midwives, and ignores the need for careful correction and improvement, is also unbalanced and may lead to tragic, preventable outcomes for the consumer, and loss of that midwife to the workforce. At present in this country any midwife is able to elect to work in a self-employed capacity, or employed privately by a midwifery group practice. A small number of midwives have chosen one of these pathways, with very little, or no postgraduate experience working in the more structured, and more supervised, environment: mainstream hospital maternity wards. Within hospital employment models a midwife who has recently graduated will be given support and a process of structured performance reviews over time. A midwife whose practice does not meet the standard expected within the unit may be asked to agree to a performance contract that includes measurable outcomes.Midwives who are practising privately form a very small proportion of the profession. Yet, we are an easy target for bureaucratic control. In the past few years we have jumped through amazing hoops in order to achieve eligibility for Medicare, and notation on the register as midwife prescribers. We are instructed and guided by the Board, the insurers, Medicare, and professional bodies, and the list of codes, guidelines and instructions grows constantly. In my opinion, there is no need for a professional supervision program for all privately practising midwives. It would be an enormous waste of resources, for very little gain.

I would like to urge the NMBA to establish a targeted professional supervision program, with a strong focus on adult learning through peer discussion and reflection, directed at those midwives who have recently commenced private practice, as well as those who have had complaints or notifications made about their private practice. The midwife may be required to comply with a program of professional supervision for a period of time, such as 5 years, or a number of episodes of care (eg 50) in which the woman is receiving primary maternity care from that midwife. The midwife supervisor would need to be a respected and experienced member of the profession, who has demonstrated her/his ability to practise midwifery in the private practice context. At the end of the supervision period, the supervisor would advise the NMBA of the midwife's successful completion, or recommend an extension. If at some time the supervisor forms the opinion that the midwife's practice does not meet the Board's standard, there may be restrictions to practice imposed, and the process of notification, investigation, and a hearing would need to be initiated. The Board has supportive processes like this available for nurses and midwives who seek help in dealing with mental health issues, or alcohol or other substance addiction.

The opinions shared and explored here are my own. I would be very happy to discuss this matter further with midwives or others, either through the comment function on this blog, or at my villagemidwife facebook site.

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Retired from clinical practice

I have retired. Joy JohnstonMobile: 0411190448

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About me

I have been a midwife since 1973, and have practised independently, attending births in homes since 1993.

My four children, born after I qualified as a midwife, taught me that the medical model of care was not suitable for a well woman. The first three, born in a hospital in Lansing, Michigan, taught me that I could push boundaries. The fourth, born at a birth centre in Melbourne Australia, opened up new possibilities, and new philosophies. The babies themselves taught me about birthing and breastfeeding. My first grand-daughter, born into my hands, has brought to my life and loving a wonderful new dimension. The birth of each subsequent grand-child has been a precious time for me.

I learn more from every woman who takes me into her life for the birth of her child. I learn more from each wonderful baby as she or he enters our world.

It is not easy to practise as an independent midwife in Melbourne. Women do not, as a rule, question the care that is available through our health system. Women giving birth are usually submissive to the dominant medical system. Options are not well understood, and not widely available.

Women who choose midwife care are discriminated against financially. Whereas free hospitalisation and subsidised visits to the doctor are available to all, care by a known midwife is usually expensive, except in isolated public hospital programs.

In recent years I have been less able to ignore ageing, and I have realised that I need to write my stories, and share my professional knowledge so that it is not lost when I am no longer able to practise.

Thankyou for visiting my blog. I hope you will find it informative and useful. Please leave a comment or contact me joy@aitex.com.au